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At least 1,117 records · Page 62Linked to original sources
PubMedDate not supplied

Lessons learned: developing education for a system-wide documentation project.

BACKGROUND: As Summa Health System implemented an integrated interdisciplinary documentation system, educational sessions for staff had to be developed and presented. METHOD: Structure of classes, scheduling of sessions, ongoing revisions and refinements, and key elements of success are shared. RESULTS: Staff members incorporated the documentation changes into practice. CONCLUSION: Other organizations may benefit and learn from the experiences of our two-hospital system in developing and scheduling education for a system-wide change project.

Computer User Training↗
PubMed2006

A standardized drawing scheme to document corneal changes following refractive corneal surgery.

PURPOSE: To present a systematic and standardized drawing scheme for unambiguous and reproducible documentation of corneal changes after incisional techniques, coagulative procedures, and lamellar and surface ablation excimer surgery. METHODS: Standardized symbols in five colors representing specific corneal conditions after incisional surgery (eg, radial keratotomy, astigmatic keratotomy), coagulative procedures (eg, laser thermokeratoplasty, conductive keratoplasty), surface ablation (eg, photorefractive keratectomy, laser subepithelial keratomileusis, epi-LASIK), and LASIK are used to record corneal changes in frontal and sectional views. RESULTS: Corneal changes following refractive corneal surgery were documented. CONCLUSIONS: The drawing scheme permits specific features to be followed in the clinic in a clear and unambiguous manner.

Cornea↗
PubMed1995

Documentation and evaluation of cognitive impairment in elderly primary care patients.

OBJECTIVE: To describe the prevalence of cognitive impairment among elderly primary care patients and to compare diagnostic evaluations and use of health services among patients with and those without cognitive impairment. DESIGN: Prospective cohort study. SETTING: Academic primary care group practice. PATIENTS: 3954 patients aged 60 years and older who completed the Short Portable Mental Status Questionnaire during routine office visits. MEASUREMENTS: Demographics and comorbid illness at baseline, diagnostic evaluations for cognitive impairment, use of standard and preventive health services, use of psychoactive drugs, and death in the year after the screening date. RESULTS: The prevalence of cognitive impairment among all patients aged 60 years and older at baseline was 15.7%; 10.5% had mild impairment and 5.2% had moderate to severe impairment. Patients with moderate to severe impairment were significantly older than patients with no impairment (76.2 years and 67.4 years, respectively), were more likely to be black (85.8% and 61.3%), had fewer years of education (7.3 years and 9.2 years), and were more likely to have cerebrovascular disease (20.4% and 6.3%) and evidence of undernutrition (30.6% and 16.9%). Dementia was recorded as a diagnosis for less than 25% of patients with moderate to severe cognitive impairment, but patients with documented impairment were more likely to have been evaluated for reversible causes. In the year after screening, patients with moderate to severe impairment were more likely than those with no impairment both to be hospitalized (29.1% and 16.5%) and to visit the emergency department (55.8% and 38.5%) but had fewer outpatient visits (6.0 and 7.6) and greater mortality (8.2% and 2.8%). CONCLUSIONS: Cognitive impairment is associated with increased use of health services and increased mortality. Patients with undocumented cognitive impairment were significantly less likely to be evaluated for reversible causes. Research is needed to determine if better documentation of cognitive impairment would improve not only diagnostic evaluations but also patient management, counseling, and outcomes.

Age Factors↗
PubMedDate not supplied

Documentation in nursing practice.

Accurate documentation is essential to maintain continuity and inform health professionals of ongoing care and treatment. It also provides legal evidence. This article highlights the advantages of accurate record keeping and the barriers to effective documentation in the community setting.

Access to Information↗
PubMedDate not supplied

Performance appraisals: more than just a feedback tool. Legal documentation for employment decisions.

Unjust discharge suits filed on behalf of disgruntled employees are becoming frequent occurrences. The employment-at-will doctrine, which has protected an employer's right to discharge employees for any reason or no reason at all, is continually being challenged. This stream of litigation has caused organizations to take a new look at how employment decisions are made. The result has been a renewed interest in the performance appraisal process--a key method in providing feedback and documenting worker performance. Aside from providing organizations with legal documentation, effective performance appraisals provide organizations with several benefits. First, feedback fosters positive actions and eliminates inappropriate behaviors. Second, the supervisor-employee relationship is improved. Third, effective performance appraisals increase motivation, morale, and job satisfaction--ultimately resulting in increased productivity.

Documentation↗
PubMed1992

Multidisciplinary documentation for home care.

Documentation serves as a primary measure of clinical practice and reimbursement eligibility and as a tool of professional accountability and quality assurance. This article presents a multidisciplinary documentation system designed to accommodate these multiple dimensions of quality home care.

Documentation↗
PubMed1992

Comprehensive clinical pharmacy documentation in an out-patient cancer facility.

Clinical pharmacy activities that affect patient outcome are a high priority in pharmacy practice. A relatively simple method of documentation for analysis of these clinical pharmacy activities in an out-patient oncology setting is described. Policies and procedures for clinical pharmacy activities were developed and formalized in an effort to standardize pharmaceutical care in the cancer facility. Consultations or drug information questions originating outside the pharmacy, as well as interventions initiated by a pharmacist were all documented on a comprehensive activity form on a daily basis by each pharmacist. All medication counseling sessions by a pharmacist were also recorded. During a 12 month study period, a total of 1828 activities were recorded. Of these, 343 (18.8%) were pharmacist-initiated interventions to drug therapy. Recommendations were accepted by physicians in 293 (85.4%) of these interventions. In 125 (36.4%) cases, potentially serious negative patient outcomes were avoided by this clinical pharmacy activity.

Alberta↗
PubMed1992

Principles of medical record documentation.

The following is an excerpt from a brochure titled "Principles of Medical Record Documentation" developed jointly by representatives of the American Health Information Management Association, the American Hospital Association, the American Managed Care and Review Association, the American Medical Association, the American Medical Peer Review Association, the Blue Cross and Blue Shield Association, and the Health Insurance Association of America. Although their joint development of this brochure is not intended to imply either endorsement of, or opposition to, specific documentation requirements, all seven groups share the belief that the fundamental reason to maintain an adequate medical record is its contribution to the high quality of medical care.

Documentation↗
PubMed1992

Medicaid program; elimination of certain written documentation pertaining to Medicaid long-term care facilities--HCFA. Final rule.

This final rule deletes a requirement in Medicaid regulations pertaining to State survey agencies, which certify facilities as meeting the requirements for participation in the Medicaid program. Specifically, we are deleting the requirement that State survey agencies, when certifying facilities with deficiencies, must provide written documentation that the deficiencies do not jeopardize resident health and safety or seriously limit the facility's capacity to furnish adequate care. Because there are already other written requirements for documentation of these deficiencies, this revision eliminates an unnecessary administrative burden, while ensuring resident health and safety.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1993

A system for documentation of pharmacist interventions with incorporation into performance and quality improvement plans.

Budgetary constraints have compelled hospital administrators to take a more discerning look at the role of the pharmacist within the healthcare team. In 1991, financial difficulties and hospital-wide cutbacks at Northern Michigan Hospital resulted in the loss of pharmacy personnel. Consequently, the department has increasingly found it necessary to document the clinical activities of the pharmacists and their potential effect on patient care. To document therapeutic interventions, two forms specific to this activity were developed. These forms allowed evaluation of both the quantity and quality of interventions. The authors realize it is essential for pharmacists to not only maintain, but to continually update their knowledge base to be prepared for the future. A staff development program was developed to help meet the educational needs of the pharmacists. This article describes how therapeutic interventions were integrated into the quality improvement and performance plans to help motivate staff to continually improve their pharmacy practice skills at this institution.

Clinical Pharmacy Information Systems↗
PubMedDate not supplied

AAMT (American Association for Medical Transcription) speaks out on confidentiality, privacy, and patient care documentation.

Increased use of technology within the healthcare system has raised concerns about the confidentiality, privacy, and security of patient care documentation. These guidelines acknowledge the responsibility and assume the commitment to protect confidentiality, privacy, and security of patient care documentation by all individuals associated with the medical dictation and transcription process. These guidelines suggest means by which such responsibility and commitment should be demonstrated.

Computer Security↗
PubMed1995

A multidisciplinary approach to enhance documentation of antibiotic serum sampling.

A procedure to improve interdepartmental communication and documentation of antibiotic serum sampling data for pharmacokinetic evaluation will be presented. A prospective audit by the Pharmacokinetic Service revealed that approximately 40% of all antibiotic serum levels were improperly drawn resulting in unsuitable specimens and erroneous serum concentrations or lacked sufficient data for pharmacokinetic analysis. A lack of communication and documentation between phlebotomy and nursing personnel was found to be the most significant source of potential error in serum sampling. Once the protocol for serum sampling was revised, less than 5% of antibiotic serum levels were found to be unsuitable for evaluation and interpretation. A continuous audit for procedural compliance identifies any source of potential sampling error and provides a means to improve the overall quality of a Pharmacokinetic Service.

Anti-Bacterial Agents↗
PubMed1996

Methods of documenting cost savings associated with an antibiotic management program.

Documenting the financial impact of an antibiotic management program is important for demonstrating the value of these pharmacy-driven or interdisciplinary services. There are several cost-saving methods that may be utilized in justifying such programs. These include intervention analysis, drug purchasing comparisons, specific agent tracking, patient length of stay analysis, and evaluation of antimicrobial therapy for a specific disease state. Several of these methods have been utilized for successfully documenting the financial impact generated by our institutions antibiotic management program.

Anti-Bacterial Agents↗
PubMed1997

Patient documentation. On the records.

Documentation of patient care is frequently the Achilles heel of clinical services. The use of a multidisciplinary, semi-structured healthcare record may achieve improvements, but it needs to be coupled with appropriate strategies to overcome professional and cultural barriers to unified documentation. When implementing changes, clinical staff may overestimate their clinical information needs while underestimating the problems of its routine collection.

Documentation↗
PubMed1998

Documentation on track with protocols.

To make sure nurses and other disciplines teaching patients were following teaching standards (and to improve documentation), one hospital created teaching protocols for several top diagnoses. As a result, its documentation jumped from 58% to 92%. The hospital took the following steps to ensure the success of the protocols: Existing protocol committees wrote teaching protocols. Clinical educators conducted staff in-services. Guidelines for implementation were created.

Case Management↗